This invention relates generally to a health insurance indemnity system in which insurance subscribers are required to make payments to service providers and then claim and collect from insurers and more specifically to an automated system and method by which an insurance company or third party payor could allow subscribers to file prescription drug claims.
Many health insurance companies and medical plans offer what is sometimes referred to as a major medical point-of-service prescription drug benefit plan. In this benefit plan, customers or insurance subscribers are responsible for paying for their prescription drugs in full. The insurance subscribers are then required to file prescription drug claims for reimbursement of a specified portion of these expenses. Typically the reimbursement amount ranges from 50% to 100% depending on the type of medication and whether or not the subscribers have reached their maximum “out of pocket” limits. The reimbursement portion can represent a significant amount of money to subscribers who have high prescription drug expenses and low or fixed incomes. Loss or misplacement of even one or two prescription receipts could result in a significant loss of money for these insurance subscribers, if they fail to file a claim for reimbursement. Information needed for filing a claim is readily available from their pharmacist should a receipt be lost, but not everyone is aware of this. It can be difficult to document and track which prescriptions have had claims filed and which ones have not. In order to track this effectively, one would need to keep a log of every prescription purchase. It would also be necessary to keep a spreadsheet to document that a claim was filed for each prescription and that the reimbursement check was received and deposited. This can be overwhelming for people who have no accounting background and unnecessarily expensive for those who have problems with memory loss. There is a need in the art to automate the filing of prescription drug claims for insurance subscribers, even though there have been significant advances in the art with regards to automating the filing and collection of insurance claims on behalf of service providers.
Boyer, in U.S. Pat. No. 6,208,973 B1 describes a Point of Service Third Party Financial Management Vehicle for the Healthcare Industry that comprises the steps of: “transmitting at least one of healthcare product and service codes for healthcare products and services purchased by the patient from a healthcare provider at a point of service to an adjudication engine for processing; The adjudication engine adjudicating the product and service codes substantially in real-time so as to determine a first portion of the purchased healthcare products and services which is to be paid by a third party payor and a second portion of the purchased healthcare services which is to be paid by the patient; the adjudication engine returning an adjudicated settlement transaction to the point of service designating at least the first portion and the second portion; formatting the adjudicated settlement transaction as a credit card transaction at the point of service; and processing the formatted adjudicated settlement transaction in a credit card network for payment”. The present invention makes no attempt to include an adjudication engine as part of the invention. It does not use a product or service code as information to be used in an adjudication process, but rather uses a claim authorization or approval number that an insurance company or third party payor issues to a pharmacist. The third party payor determines an applicable reimbursement amount and that adjudication process is not within the scope of this invention. Boyer's invention does not address needs of insurance subscribers where their insurance company or third party payor does not subscribe to his Point of Service Third Party Financial Vehicle.
Richard O Ullman in Patent Application Pub. No.: US 2002/0002495 A1 describes an invention that relates generally to the field of consumer prescription and other healthcare programs and more particularly to an integrated consumer rewards program for prescription medication users. A participating consumer with one card, can instantly purchase pharmaceuticals and charge the transaction to a credit card and earn and apply savings dollars redeemable for pharmaceutical purchases. The invention claims a system for managing pharmaceutical accounts comprising: a plurality of points of sale, said points of sale adapted for transacting pharmaceutical sales with consumers; a processor coupled to said plurality of points of sale, said processor adapted to adjudicate claims associated with said pharmaceutical sales; and a financial processor coupled to said processor for processing any electronic financial transactions associated with said pharmaceutical sales; whereby a percentage of said pharmaceutical sales is credited to a rewards account for said consumers. Again, the present invention does not use a processor adapted to adjudicate claims and does not include a rewards program. Ullman's invention does not address the needs of insurance subscribers where their insurance company or third party payor uses its own adjudication process for determining the applicable reimbursement amount and requires subscribers to file claims for reimbursement.
Robert G. Mahaffey, in Patent Application Pub. No.: US 2003/0195773 A1 describes a method for payment of healthcare charges by paying the amount due with a healthcare credit card and the patient receiving a first discount from the amount due. The credit card issuing company pays the healthcare provider an amount equal to the patient charge less the first and less a second discount. The healthcare provider minimizes its accounts receivable, the patient receives a discount from the amount due and the charge card issuer earns a profit due to a payment to the healthcare provider of a double discounted amount while collecting from the patient a single discount amount. The present invention does not use the discounting scheme described in this patent application. Mahaffey's invention does not address the needs of insurance subscribers where their insurance company or third party payor uses its own adjudication process for determining the applicable reimbursement amount and requires subscribers to file claims for reimbursement.
The above mentioned patents describe the use of payment cards to automate the adjudication of claims and the securing of rewards or discounts, but they do not address the specific situation that the present invention addresses. That situation is that under some prescription drug programs it is necessary for the program subscribers to pay for their prescriptions in full “out of pocket” and then file prescription drug claims for reimbursement. If subscribers fail to file claims, the subscribers lose the reimbursement amount that they are due according to terms of their insurance contract. The present invention addresses this problem.
Furthermore, prescription drug insurance companies must pay employees to manually process their prescription drug paper claims. If employed, the present invention should considerably reduce expenses associated with processing paper claims. The present invention has been designed to meet the need in the art to automate the filing of subscriber prescription drug claims where a claim authorization or approval number has been issued by the third party payor prior to a sale.